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There was no warning when gunmen killed seven aid workers with local NGO Support With Working Solution (SWWS) in the Swabi District of Pakistan's Khyber-Pakhtunkhwa (KP) Province on 1 January.

"We had never received a direct threat, since we began work in the early 1990s," Javed Akhter, executive director of SWWS, told IRIN, adding however that "other NGOs in the Swabi area have felt a sense of intimidation."

Chris Cork, country security adviser for the UK-headquartered Abaseen Foundation, an NGO working chiefly in KP, told IRIN: "NGO security threats are at an all-time high. I have never in almost 20 years known things as bad as this."

Over the past few weeks there has been an upsurge in attacks on aid workers, many of them linked to a national polio eradication campaign in one of the world's last three countries where the disease remains endemic.

In December 2012 the UN Children's Fund (UNICEF) and the World Health Organization (WHO) suspended their anti-polio vaccination campaign after nine workers were killed in attacks in Karachi and KP.

Polio workers, including those working for the UN, were also targeted earlier in 2012.

Beyond the polio campaign, aid workers in general are starting to feel more hostility to their work.

In an attack on 5 January, two aid workers with Al-Khidmat Foundation, an NGO working in education, were shot dead in the northwestern city of Charsadda.

Last month Birgitta Almeby, a 71-year-old Swedish charity worker, who had worked in the country for 38 years for the church-based Full Gospel Assemblies, died in a Stockholm hospital after being shot in the eastern city of Lahore.

In April 2012 Khalil Dale, a British Muslim health worker employed with the International Committee of the Red Cross, was found beheaded after being kidnapped in Quetta, leading the organization to "reduce" activities in the country for several months.

Calls for more state protection

Cork of the Abaseen Foundation said due to the current "febrile environment field workers are going to die in increasing numbers as the state is unable in some cases and unwilling in others to offer protection. Until the state is willing to fulfil its side of the social contract, all workers in the field, particularly women in health and education, are at an elevated level of risk."

The KP government says it is doing its best to protect aid workers.

"We oppose militancy, and are ready to do everything possible to ensure people in need receive the help they need - whether this is to deliver polio drops, education or other assistance," Mian Iftikhar Hussain, the information minister for the KP provincial government, told IRIN.

The attacks are making aid workers feel vulnerable: On a recent three-day anti-polio drive [ ] run by the local health department in Bajaur Tribal Agency, a doctor, who asked to remain anonymous, told IRIN: "Several local female workers refused to go into the field due to fear," though the campaign turned out to be peaceful.

Meanwhile, the president of the paramedical association of Mansehra District in KP, Khalid Khan, has sought protection for anti-polio workers. Khan told the media that until the polio workers were given protection they could not perform their duties.

In Pakistan's fractious society, aid workers operate in a highly contested space and are not always welcome.

A recent report by the Pakistan Humanitarian Forum, an umbrella organization for over 40 NGOs engaged in relief work, identified a worsening climate for international aid workers with more visa restrictions for those seeking to enter or stay in Pakistan.

From January to September 2012, a reduction of 60 international aid workers was observed across international NGOs, mainly due to delays in obtaining or extending visas.

Mian Iftikhar Hussain denied any knowledge of this, but an official at the Foreign Office in Islamabad who asked not to be named, told IRIN: "Every time a foreign aid worker is injured, kidnapped or killed in Pakistan it is an embarrassment for the government. For this reason, there may be a reluctance to allow more to come in."

Origins of hostility

While humanitarian principles of humanity, neutrality, impartiality and operational independence may seem unthreatening, aid workers have found themselves caught up in political, ethnic and religious tensions.

The Foreign Office official told IRIN: "Militants' fear that NGO or health workers could be spies, may be spreading into other realms," an allegation that predates 2011, but which was reinforced by the death of former Al-Qaeda leader Osama Bin Laden in May of that year.

In 2011 Shakil Afridi, a government-employed doctor, collected DNA samples from a residential house in Abbotabad which helped the US Central Intelligence Agency identify the whereabouts of Bin Laden, who was killed in a US raid. It is alleged that Afridi, since sentenced to 33 years in jail, masqueraded in his native Khyber Agency as a polio vaccinator in order to collect the samples.

Ehsanullah Ehsan, a spokesman for militant group Tehrik-e-Taliban Pakistan, told IRIN: "Afridi was a traitor and naturally people now suspect all anti-polio workers of being US agents."

Health worker Shahida Bibi, 40, who works in the Mardan District of KP and has regularly participated in anti-polio campaigns, told IRIN: "this is certainly a factor in recent attacks on polio workers."

She also said other notions, like the "myth sometimes spread by clerics that polio drops cause sterility and are a `Western conspiracy' to reduce Muslims in the world", sometimes accounted for hostility and refusals by parents to have children vaccinated.

Security concerns look set to hamper efforts to deliver aid, and eradicate polio in particular. In 2011, Pakistan had 198 cases - more than anywhere else in the world, according to WHO.